How do medical schools influence their students’ career choices? A realist evaluation

Figures & data

Figure 1. Initial programme theory of how career preferences are formed in medical school.

Table 1. Participants’ stated career choice at the start of medical school and at interview (FY2).

Participant	Career intention pre-med school	Intended Career at interview
K01m	none	GP/Medicine
K04f	Psychiatry	Psychiatry
K15f	Neurology	Pathology
K17m	none	Orthopaedics
K23m	GP	Acute Care Common Stem
K28f	none	Acute Care Common Stem
K30m	Psychiatry	Acute Care Common Stem
K33m	GP	GP
K38m	none	Medicine
K40f	Hospital doctor	F3/GP
K42f	Obstetrics&Gynaecology	Obstetrics&Gynaecology
K43f	none	Emergency Medicine
K44f	histopathology	GP
N03m	none	Surgery
N04m	Obstetrics&Gynaecology	Obstetrics&Gynaecology
N05f	Pathology	Medicine
N07f	none	Neurology
N08m	none	Paediatric Surgery
N09f	Paediatrics	Paediatrics
N13f	none	F3/Acute Care Common Stem
N14f	none	GP
N17f	Surgeon	GP
N19f	GP	GP
N24m	GP	Acute Care Common Stem
N25m	Trauma	Obstetrics&Gynaecology
N26m	Psychiatry	F3/Acute Care/GP

Table 2. Exposure to specialities.

CMOc	Illustrative quotes
1a. A brief exposure to a few aspects of the speciality (C) if it is appealing to that individual (C) is not sufficient in itself to trigger a career choice but can result in a desire to test for fit (M) by choosing a longer exposure (O). 1b. Brief exposure to a speciality (C) if it is not appealing to that individual (C) or the providers are not engaging with student needs (C) may trigger discomfort (M) or boredom (M) which may result in immediate ruling out without further consideration of testing for fit (O)	We weren’t actually really exposed to anaesthetics during Medical School until our final year when we did … a week of A&E, a week of anaesthetics, a week of ITU. I hadn’t really found anything as enjoyable as I did find that so I chose that for one of my foundation jobs just to get a bit more exposure to it … and that was it. I knew pretty much after that that’s the career for me and then subsequently since I’ve done other jobs during F1/F2, I realise that nothing’s actually come up to that level for me in terms of enjoyment K23m Psychiatry I just hated … . I remember we spent an hour in the morning having little ward rounds and we spent 40 minutes of that talking about the furniture in someone’s room and I just thought, no. This isn’t for me. So that’s one speciality that got ruled out fairly quickly. The second was paediatrics. I did paediatrics in xxxxx and there wasn’t really that much engagement to teach us. N03m
2a. Long placements give adequate exposure to the realities of a speciality (C) to enable testing for fit (M) both of aptitude for it and satisfaction in doing it which may lead to contemplating it as a career (O) if the fit is good. 2b. Adequate exposure to the realities of a speciality (C) will allow realisation that the fit is not actually good (M) if there is lack of task interest (C), lack of personal aptitudes(C), or wrong level of challenge/pace(C). This may cause ruling out (O) and seeking a career with the opposite characteristics (O)	I enjoyed my GP placement as a fifth year and then I enjoyed it as an F2, which has consolidated my decision really. But I’d say there wasn’t like an epiphany moment. It was kind of a gradual, ‘Yeah, I think I want more people’ K44f Even though I enjoyed the actual placement, for me that really did make up my mind. Maybe if that had been a shorter placement I probably would have still kept that as an option but because it was so long I think that really did let me almost become a GP for that length of time and then after that you realise I can’t do that forever. K23m
3a. In students who already had a career preference on joining medical school (C1) exposure to that speciality especially in early years (C2) may be strongly and memorably confirmatory (O) through enhancing the existing interest (M1) and fit may be perceived (M2) without much evidence. Consideration of alternatives may therefore be blocked (M3). 3b. If the original career preference is weak (C1), exposure to other specialities (C2) and discovering more about their original speciality of interest (C3), triggers testing for fit (M) which may lead to altered preferences (O).	The last block in the first year was female anatomy and all that sort of stuff and that was like my favourite block of the year so I guess that cemented it and I remember X coming in one day and just being like, sorry guys I’m late I was elbow-deep in placenta and everyone else was like ewwww and I was like I want to do that! That’s what I want to do so, and then it’s just kind of gone on from there K42f In the pre-clinical years, there was quite a lot of histology and I actually really enjoyed that so that kind of consolidated the fact that I wanted to do it. I did an SSC in it in third year. And I think at that point I was kind of realising that I actually quite like people alive. So then it was sort of go down that route. K44f

Table 3. Being given an active role and exposure to role models.

CMOc	Illustrative quotes
4. Being given an active role (C) and discovering enjoyment of it (M1) and getting self-efficacy (M2) are powerful emotional triggers to finding ‘fit’ and developing a career preference for that speciality (O)	On the five week emergencies block, my week in anaesthetics I actually really enjoyed and I was given a fair amount of responsibility on the practical procedures and started to really enjoy that K30m
5. Being cared for socially/being treated as a legitimate part of an attractive community of practice (C1) and receiving approval in the role (C2) was another emotional reinforcement (M) of the sense of ‘fit’ for that speciality (O)	So it definitely was a sense that this is a speciality where I felt kind of valued and I felt like the other juniors were valued and it was quite a friendly environment to be in so that definitely influenced me, yes N09f
6a. Medical students may be inclined to identify with (M) attractive, successful, knowledgeable, enthusiastic role models who involve and encourage them (C) and therefore may want to follow their career (O1) or may on reflection wish to adopt their attributes but not their career (O2). 6b. Observing an role anti-model (C) may cause antipathy to joining their community of practice (M) resulting in ruling out their speciality (O)	There’s some really interesting consultants that were really kind of inspiring actually and really dedicated to the job and seeing that made me realise that maybe I would want to be like that but erm I think it’s more the personalities rather than the science that I enjoyed in renal. We all got along really well which was really nice. But I don’t think I’m a renal physician at heart. I think I just really liked the team. N04m She was a female surgeon and she was I think quite honestly the rudest person I’ve ever met in my entire life and she put me off wanting to do surgery. Just if people are like her, I want nothing to do with it K04f

Table 4. Student choice.

CMOc	Illustrative quotes
7. The option of Student Selected placements (SSCs)/Electives (C1) and voluntary extracurricular activities (C2) enable students to actively seek exposure to test for fit (M) with the outcome of clarity about a career in that speciality (O)	I think in my head I was basing my placements around, oh yeah they’ll be useful for GP. So for my other SSC I chose ENT and … I did another paeds one as well because it is useful for GP, erm, I quite liked being in community and the range of patients and, I quite liked going out for home visits, I quite like seeing people in their home environment that was quite nice! K40f

Table 5. Medical school culture, the hidden curriculum.

CMOc	Illustrative quotes
8. A culture of encouraging individual students to discover their interests (C) will promote testing for fit (M) with the outcome of more exploration of the clinical environment (O1) and questioning of senior colleagues (O2)	I think xxxx were quite good actually cus they just said … keep thinking about it and enjoy the placements you go to, if you know what you’re gonna do, fair enough, do a bit of work towards it … . they encouraged you to kind of get going with stuff that would help for your career but probably were less pushy about making decisions. They were very open that probably most of the people who make a decision at Medical School might change it in F1 or F2 N05f
9a. The shape of the curriculum (C1), statements suggesting a career in GP (C2) can feel affirming (M) and make the choice more settled (O) for students who were wanting to be GPs (C3) 9b. To students who were wanting to keep options open (C4) (C1) &; (C2) and peer opinion that it is the fall-back option (C3) can feel like pressure needing to be resisted (M) and cause a stronger resolve not to pursue that career (O)	K is always going to encourage people to be GPs because of the way the course is designed. They’ve invested heavily in GP placements. They’re very good placements … I think the course lends itself well to being a GP and I’m sure that’s one of their underlying aims. I don’t know. Lots of our most influential tutors are GPs. Lots of the higher Faculty are GPs. K01m There might have been the occasional remark off lecturers and things, er, but there was a general student consensus that we were a heavily general practice university and a lot of us turned out to be GPs. And it was almost like a negative thing, like if you’re a xxxx graduate … you’re going to be a GP, and a lot of people were trying to fight against that and I think I was as well. I was like, ‘Well I’m not going to be a GP if that’s what everyone else does’. Erm, so when (we) left medical school there were very few of us who were actually going to do GP and actually now, erm, my cohort’s got to the end of F1 a lot of them are doing GP. Erm, it was almost like it was looked down on at medical school. N14f
10. Missing elements of a curriculum (C) effectively minimize by omitting opportunity (M) the possibility of certain careers (O)	One thing you’ll notice is we didn’t really have that much GP compared to a lot of Medical Schools, or that much community placement. Nothing to do with palliative, you know nothing in hospices but yes, a lot of the focus was on being a hospital doctor or surgeon I think. N04m
11. Medical schools representatives’ voiced opinions (C) may colour (M) the forming perceptions of stigmatized careers making them appear unattractive (O)	In the first six months of medical school I had already got that impression that if you were a smart doctor you did hospital medicine and if you were not so good you ended up in general practice. I remember, on the open day for xxxx University, erm, the opening lecture they made a point about saying, ‘At least half of you will become GPs and you won’t want to be’. xxxx University’s quite snobbish in a lot of ways, erm, and there were quite a few times when they, someone would say a line about, ‘Well a certain percentage of you will by necessity become GPs but xxxx tends to have a higher proportion of hospital doctors than, than general practice doctors, and that reflects the quality of the students we have’. N24m

Table 6. Career guidance.

CMOc	Illustrative quotes
12a. Personalised one-to-one discussions with a career advisor (C1) and the Sci59 career aptitude questionnaire (C2) may enhance self-awareness (M1) and encourage testing of fit (M2) with particular career options leading to looking into them more (O1) and provide material for application forms (O2). 12b. The Sci59 suggestions (C2) may be difficult to interpret (M3) and get discarded (O3)	I had a meeting with the careers adviser so I did the Sci 59 thing and then I had the opportunity to meet with someone and go through my results and try and make sense of them all and that was actually really useful because … the Sci 59 comes out with specialities that might suit you and rather than just going through and saying oh well this speciality does this and this speciality does that, she actually looked through and worked out the pattern. Which helps you sort of understand yourself a bit better and why you might be suited to certain specialities…. (and) certainly when you’re doing your applications and it says why do you’re think you’re suitable for this specialty? Actually a lot of that probably came from sitting down and thinking about it with the careers advice back at Medical School K28f I did do the SCi 59 and spoke to somebody at the University from the career support team but I didn’t find that particularly helpful the sSCi 59. I think they told me that I should be a haematologist in super rare blood conditions (laughing) which you know, had never appealed and I’ve never really thought about since K17m
13. Informal career guidance solicited (M1) from doctors in that job (C) may be valued (M2) more than formal for some students and FY doctors in order to find out what a job feels like (O)	Senior Registrars or Consultants will have done a bit of training in another speciality and changed and seen that it’s not for them and sometimes those conversations can be quite useful because you find out why it wasn’t for them and you can consider whether that will be a factor for you K28f
14a. Unsolicited informal advice about how to choose a career from trusted clinical supervisors (C1) may facilitate testing for fit (M1) and refine the decision (O) 14b. Doctors’ unhappiness in their speciality (C2) influences students powerfully (M2) and can trigger ruling out (O2)	I think one of my old bosses just said that you need to decide what’s important for you whether that’s, you know, the type of patient, whether it’s doing practical stuff, whether it’s prestige or lack of prestige, whether it’s lifestyle stuff … . So for her it was the kind of patient mix that she got. For other people it’s doing procedures. For other people it’s not being in a job that’s looked down on or whatever so you just decide based on that. N08m He said it’s a changing specialty and it’s not what it used to be and maybe you should stay away from this one … so I think he sort of helped in terms of putting me off general practice as a speciality, partnership disputes and all sorts of ugly stuff like that so he advised against GP which I will listen to his advice on N03m

Figure 2. Final programme theory Model of how career preferences are formed in medical school.